NOTICE OF PRIVACY PRACTICES

THIS NOTICE ILLUSTRATES HOW YOUR MEDICAL INFORMATION MAY BE USED, DISCLOSED, AND ACCESSED.   

PLEASE READ IT CAREFULLY.

 

This Notice is in effect as of 01/01/2013.

 

We are required by law to maintain privacy and protection of your health information and must inform you of your privacy practices and legal duties.  You have the right to obtain a paper copy of this Notice at any time.

 

We, Northland Psychological Services, serve as the designated Privacy Officer to answer your questions about our privacy 

practices and to ensure compliance with applicable laws and regulations.  The Privacy Officer is responsible for addressing complaints and providing you information on how to file a complaint.  

 

USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION REGARDING TREATMENT, PAYMENT, AND

HEALTH CARE OPERATIONS

 

Information contained in your records may and will be used to provide your treatment.  We may disclose information in your record to aid you in obtaining health care services from other providers, e.g. hospitals. This information may be disclosed in order to obtain consultation regarding recommendations to the most current, appropriate, and effective treatment services.

 

Information contained in your records may be used to obtain payment for the services you received.  For instance, We may 

submit your diagnosis with a health insurance claim in order to illustrate to the insurer what services are to be covered.

Information contained in your records may be used to assist in health care operations.  These operations include but are not 

limited to reviewing records for efficacy, contacting you regarding treatment alternatives, and coordinating care with other 

providers.

 

YOUR RIGHTS

 

You may request restricted use and/or disclosure of certain information in your record that otherwise would be allowed for 

treatment, payment, or health care operations.  Your request will be reviewed; however, this Licensed Psychologist will utilize their  best clinical opinion to either grant or deny the request.  Requests will need to be prepared in written form and will become part of your record.

 

You have the right to receive confidential communication.  Please notify us immediately to provide alternative contact 

information.

 

You have the right to review the information in your record, and may obtain a copy.  The request may be subject to certain 

limitations and fees.  Information received from other providers will not be copied and must be obtained from the original service provider.  Your request must be in writing.

 

If, upon review, you believe information in your record is inaccurate or incomplete, you may request an amendment of the 

information.  You must submit sufficient information to support your request.  Your request must be in writing.

 

You have the right to request an accounting of certain disclosures.

 

You have the right to a verbal or written complaint regarding this privacy policy (including the actions of this Licensed 

Psychologist and support staff with respect to the privacy of your health information).  You have the right to complain to the

Secretary of the Department of Health and Human Services about this privacy policy without the fear of retribution.  

 

Social & Rehabilitation Services 

Department of Health & Human Services 

Washington, DC 20201

 

Except as described in this Notice, your records will not be released or information utilized unless you have provided your written authorization.  You may revoke an authorization in writing at any time; however, this will not affect any use or disclosure made prior to your revocation.  In addition, if the authorization was obtained as a condition of obtaining insurance coverage, the insurer may have the right to contest the policy or a claim under the policy even if you revoke the authorization.

 

USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION THAT WE ARE ALLOWED OR REQUIRED BY 

LAW TO MAKE WITHOUT YOUR PERMISSION

 

There are certain situations where licensed psychologists are allowed to disclose information from your record without your 

permission; e.g. suicidal or homicidal ideation, dangerous psychotic behavior, abuse of a minor, etc.  In these situations, we will utilize our best clinical judgment before disclosing information about you.  We will determine if disclosure is in your best interest and that this act meets all guidelines and regulations put forth by our profession.

 

If you receive mental health care, including treatment for substance abuse, information related to that care may be more 

protected than other forms of health information.  Communications between a licensed psychologist and client in treatment are privileged and may not be disclosed without your permission, except as required by law.  We are required by law to report suspected child abuse and neglect, and may have to breach confidentiality if you appear to pose an imminent danger to yourself or others in order to reduce the likelihood of harm to you or others.  Information regarding suspected cases of abuse, neglect, or domestic violence involving adult victims including disabled victims may be reported.  Information from your record may be used or disclosed if it is perceived as necessary to prevent or lessen a serious or imminent threat to the safety of a person or the public.  

 

Information concerning births and deaths, certain types of diseases, injuries, adverse drug interactions, and product defects may be reported to the public health authorities.  Information from your record may be disclosed to a medical examiner or coroner.  Information may be disclosed to funeral directors to allow them to carry out their duties upon your death.  Information may be disclosed from your record to facilitate organ, eye, or tissue donation and transplantation.

 

Assistance to identify health oversight activities, such as investigations of possible health care fraud will be given.

 

Information from your record may be disclosed as authorized by worker’s compensation laws.

 

Information may be disclosed from your record if ordered to do so by the court, grand jury, or administrative tribunal. Under certain conditions, we may disclose information in response to a subpoena or other legal process, even if this is not ordered by a court.

 

Information from your record may be disclosed to a law enforcement official if certain criteria are met; e.g. to locate or identify a missing person.

 

If you tell myself or the support staff that you have committed a violent crime that caused serious physical harm to the victim, this information may be disclosed to the authorities.  However, if this information is revealed during a counseling or psychotherapy session or in the course of treatment for this sort of behavior, this information may not be disclosed to law enforcement.

 

Information regarding your records may be used in research under certain conditions.

 

Under certain conditions, information from your record may be disclosed for specialized government purposes, such as the 

military, national security and intelligence, or protection of the President.